Ark Transitional Housing-Discipleship Program Phone: (206) 947-2117
I hereby apply for membership at Ark House at the residence listed below. Answer all questions that apply.
If you have been in alcohol/drug/other addiction treatment, either in-patient or out-patient within the last three years, give the name of each program (i.e. detox, treatment center, transitional house, halfway house, hospital), the dates you attended, contact info, and the reason for leaving.
List names and telephone numbers of two individuals who may be contacted in the event of an emergency.
This page is secured with an industry leading up to 256-bit encryption SSL certificate so your personal information is always transferred securely.